The Jones Brown Law Blog

The crisis in the U.S. has shifted from opioids to the potent painkiller Fentanyl. As the White House and Congress continue to “investigate” the issue, the death toll is on the rise reaching more than 49,000 in 2017. That is an increase of nearly 7,000 over the previous year, itself a record-breaking year. It seems that the agent of death is no longer ordinary prescription painkillers. It is Fentanyl, a prescription drug that is being mixed with heroin and other street drugs.

What does this new information mean? This new information calls for an equally drastic shift in the effort to prevent opioid deaths. Tighter controls on prescriptions for oxycodone and hydrocodone are no longer enough to limit the supply. The U.S. needs a comprehensive and multi-targeted strategy to restrict the importation of illicit Fentanyl, and broader, better-funded push to reduce its demand.

Since 2011, fatal overdoses from drugstore opioids alone have remained relatively stable, but those involving Fentanyl have shot through the roof. The far more lethal drug played a part in 60% of opioid deaths in 2017, according to the National Center on Health Statistics, up from 11% last year.

Fentanyl, created in 1960 as a treatment for extreme pain associated with cancer, has become popular on the black market in part because it is synthetic. There is no need to plant and protect acres of poppy fields; Fentanyl can be cooked up in a lab. And because of its potency – a few grains pack a deadly dose – it can be mailed around the world in small, concealable packages. Drug labs in China fulfill online orders form American users, or from drug traffickers in the U.S. and Mexico who add Fentanyl to heroin and other street drugs in order to boost their effect or press it into phony prescription-opioids pills.

A coordinated response to the crisis needs to start with China, which, according to U.S. law enforcement agencies, is the source of almost 100% illicit Fentanyl. Poorly monitored and regulated chemical laboratories in China sell Fentanyl or it’s precursors to U.S. users and dealers, or to Mexican drug suppliers who in turn market it in the U.S.

The Obama administration had begun to enlist the Chinese government’s help in policing producers, including by persuading China to add many analogs of Fentanyl to its list of controlled chemical substances. President Trump has preferred to accuse and threaten, which does not encourage cooperation from the Chinese government. What is needed is a steady and purposeful diplomatic push, along with experts support for fortifying China’s capacity to inspect and regulate its thousands of drug labs.

From China, the pipeline flows mainly through the mail to users and dealers. Congress recently provided Customs and Border Protection with more chemical-detection equipment to screen packages. But given the volume of mail, scanning all of them isn’t possible. The task would be easier ifCongresss passed pending legislation to require the U.S. Postal Service to obtain basic identifying information from senders – including the name and address of the sender and a description of the contents of a package – just as private parcel companies do.

Even so, a significant amount of the drug is likely to escape detection. Strenuous efforts will continue to be needed to crack down on the market within the United States. The Justice Department made progress recently by working with Dutch authorities to shut down two major sites on the dark web where deals were made, usually in cryptocurrency such as bitcoin.

Fentanyl is also sold on the ordinary internet, and Scott Gottlieb, the commissioner of the Food and Drug Administration, is right to demand that internet companies work harder to remove all the illegal listings. The FDA, for its part, could help limit supply by restricting off-label prescribing of legal Fentanyl to patients who don’t need, and may be harmed by, such a powerful painkiller.

The demand side must be confronted as well. More than 2 million Americans have opioid-use or heroin-use disorders, and few can be expected to quit without help. They need to be brought into treatment ever opportunity, most obviously when they enter hospitals, emergency rooms or prisons. And this treatment should include methadone, buprenorphine and other opioid-based medications, which along with behavioral modification therapy have proven to be effective in overcoming addiction.

Up until now, the Trump Administration has ignored the need for medication-assisted therapy. Congress is considering Bills that would expand its use somewhat – for instance, by getting Medicaid and Medicare to fund it more generously – but lawmakers aren’t making this the priority that it ought to be. Consider that, today, only 5% of U.S. doctors have had the training required to prescribe buprenorphine; far more doctors, as well as nurse practitioners and other health-care providers, should have the authority.

Fentanyl and other opioids are killing more than 130 people a day. The crisis demands a thorough, well-coordinated national response. What the White House and Congress have come up so far falls short.

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